East Asian Arch Psychiatry 2023;33:15-20 | https://doi.org/10.12809/eaap2244

ORIGINAL ARTICLE

Meaning in Life and Depression in Low-Income Families in Hong Kong during the COVID-19 Pandemic
Ester Mui Chen, Benson KK Chan, Allen TC Lee

Abstract

Objective: To determine whether meaning in life (MIL) was associated with a lower risk of depression in people from low-income families during the COVID-19 pandemic.

Methods: Individuals from low-income families were recruited at a community centre during the fourth wave of the COVID-19 pandemic in Hong Kong. Levels of MIL were assessed using the Meaning in Life Questionnaire (MLQ). Severity of depressive symptoms was assessed using the Patient Health Questionnaire-9 (PHQ-9). Scores of ≥24 on the Presence of Meaning subscale (MLQ-P) and Search for Meaning subscale (MLQ-S) were considered high. A score of ≥10 on the PHQ-9 was indicative of clinical depression. Correlations between MLQ and PHQ-9 scores were examined, along with associations between presence of/search for meaning and risk of clinical depression.

Results: Among 102 participants, 64 (62.7%) had clinical depression; 14 (13.7%) had both high presence of meaning and high search for meaning. The MLQ score was correlated with the PHQ-9 score (r = -0.56, p < 0.001). The adjusted risk ratio for depression was 0.31 (p = 0.006) in participants with both high presence of meaning and high search for meaning.

Conclusion: Among people with lower socioeconomic status, MIL may be important for protecting against depression during the COVID-19 pandemic.

Key words: COVID-19; Depression; Low socioeconomic status; Poverty; Psychological resilience


Ester Mui Chen, The Mental Health Association, Hong Kong SAR, China
Benson KK Chan, The Mental Health Association, Hong Kong SAR, China
Allen TC Lee, Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong SAR, China

Address for correspondence: Dr Allen Lee, Department of Psychiatry, The Chinese University of Hong Kong, G/F, Multi-Centre, Tai Po Hospital, Tai Po, New Territories, Hong Kong SAR. Email: allenlee@cuhk.edu.hk

Submitted: 16 September 2022; Accepted: 13 February 2023


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Introduction

The COVID-19 pandemic is a major public health problem worldwide. To minimise the risk of COVID-19 transmission, various precautionary measures have been adopted (eg, wearing masks in public, hand hygiene, social distancing, travel restriction, and school closure). Although these measures are important for preventing COVID-19 transmission, some may have negative impacts on mental health and are associated with depression, anxiety, insomnia, loneliness, social isolation, and cognitive impairment.1-8 Moreover, many people have experienced prolonged financial difficulties because they lost their jobs or earned less income during the COVID-19 pandemic. In Hong Kong, the unemployment rate increased to >7.0% by the end of 2020, and the underemployment rate also reached a record high.9 Although Hong Kong residents have a very high rate of adherence to precautionary measures,10 acquisition of surgical masks, hand sanitisers, and household cleansing products, and stockpiling of food and daily essentials increase the financial burden, particularly for people living in poverty. Furthermore, the presence of all family members at home for longer periods of time has led to increases in conflict and domestic violence.11-13 Therefore, low-income families have higher risks of mental health problems during the pandemic.14,15

Among people at risk of mental health problems, individuals who have a sense of meaning in life (MIL) exhibit better mental health.16 Having a sense of MIL enables people to have a better understanding of their experiences, achieve a sense of worthiness, identify things that are important to them, and manage their life stressors more effectively.17 The presence of meaning is more than simply feeling happy or perceiving that life is good.18 Meaning in life is the extent to which one’s life is experienced as making sense, as being directed and motivated by valued goals, and as mattering in the world.19 People with MIL potentially have greater resilience against depression and anxiety,20 and in times of crisis.21 Meaning in life also appears to play an important role in achieving remission of mental illness.22 Strategies to improve a sense of MIL have been established;23 enabling people to achieve better mental health.17,24

Considering the high prevalence of mental health problems during the COVID-19 pandemic, as well as the potential role of MIL in mitigating the risk and progression of mental illness, this study explored whether a higher level of MIL was associated with a lower risk of depression among people from low-income families during the pandemic. We hypothesised that individuals with a higher level of MIL would experience fewer depressive symptoms.

Methods

This cross-sectional study was conducted during the fourth wave of the COVID-19 pandemic in Hong Kong (between 24 November 2020 and 6 January 2021) at the Integrated Community Centre of Mental Wellness, which provides accessible community support and social rehabilitation services to Hong Kong residents and is run jointly by the Social Welfare Department and a non- governmental organisation. A convenience sampling was used. The centre’s social workers first identified eligible individuals and then invited them to participate. Written informed consent was obtained from each participant; no incentives were offered for participation. Individuals who agreed to participate completed a self-report questionnaire, which required 10 to 15 minutes to complete. Participants’ names were not collected. This study was approved by the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong (reference: SBRE-20- 185) and was conducted in accordance with the tenets of the Declaration of Helsinki.

Participants were Hong Kong Chinese residents aged ≥18 years from low-income families, which were defined as those with a household income of ≤50% of the territory- wide median income among households of the same size.25 Individuals who could not communicate or were mentally unfit to provide informed consent were excluded, as were those with any acute or chronic condition that limited their ability to participate.

The Patient Health Questionnaire-9 (PHQ-9)26 was used to assess depressive symptom severity. The PHQ-9 is a self-administered nine-item scale based on the depression module from the DSM-IV. Respondents rate the frequencies of nine symptoms over the past 2 weeks on a four-point Likert scale that ranges from 0 (not at all) to 3 (nearly every day). The total score ranges from 0 to 27; higher scores indicate greater depression severity. The Chinese version of the PHQ-9 has been validated.27,28 The PHQ-9 scores can be used to stratify depression severity (0-4: minimal, 5-9: mild, 10-14: moderate, 15-19: moderately severe, and ≥20: severe). Individuals with scores ≥10 are considered to be clinically depressed.29

The Meaning in Life Questionnaire (MLQ) was used to assess MIL. The MLQ is a self-rated questionnaire originally developed by Steger et al.30 Respondents rate 10 items on a 7-point Likert scale that ranges from 1 to 7. The total score ranges from 10 to 70; higher scores indicate a greater sense of MIL. The Chinese version of the MLQ has good reliability and validity in Hong Kong populations.31 The MLQ assesses two dimensions of MIL: the Presence of Meaning subscale (MLQ-P) that measures the subjective sense that one’s life is meaningful and the Search for Meaning subscale (MLQ-S) that measures the drive and orientation towards finding meaning in one’s life.30 The total score of each subscale ranges from 5 to 35; higher scores indicate a greater sense that one’s life has a valued meaning and purpose (MLQ-P) and a higher level of motivation in finding meaning or purpose in one’s life (MLQ-S). Subscale scores of ≥24 indicate high presence of meaning and high search for meaning.

Statistical analyses were performed using SPSS (Windows version 26.0, IBM Corp, Armonk [NY], United States). Descriptive statistics were used to summarise all variables. The prevalence of clinical depression was determined based on the proportion of participants with a score ≥10 on the PHQ-9. Independent t tests were used to compare continuous variables between participants with and without depression, whereas the Chi squared test was used to compare percentages of categorical variables between the two groups. The threshold for statistical significance was set at p < 0.05 (two-tailed). Pearson correlation coefficients were used to assess correlations between MLQ and PHQ-9 scores. Assuming that the MLQ score was the independent variable and depression was the dependent variable, linear regression was performed to determine whether a higher MLQ score was associated with a higher PHQ-9 total score; Poisson regression was performed to determine whether high presence of meaning and/or high search for meaning was associated with a lower risk of clinical depression. Analyses were repeated after adjusting for potential confounding factors (age, sex, education level, marital status, religious beliefs, employment status, and monthly household income) with p < 0.10.

Results

In total, 102 participants (57.8% women; mean age, 51.2 years) were included (Table 1). Most participants had secondary education or above (81.4%), did not have religious beliefs (67.7%), and were unemployed (79.4%). The mean monthly household income was HK$6758.2. The mean PHQ-9 score was 12.3; 62.7% of participants had clinical depression. The mean PHQ-9 score in the depressed group was 16.8 indicating moderately severe depression. Only 17.6% and 21.6% of participants had high presence of meaning and high search for meaning, respectively.

Compared with the non-depressed group, the depressed group was slightly younger (55.0 vs 49.0 years, p = 0.04) and predominantly female (39.5% vs 68.8%, p = 0.004). The two groups were comparable in terms of education level, marital status, religious beliefs, employment status, and monthly household income.

Compared with the non-depressed group, the depressed group had lower mean MLQ total score (30.5 vs 43.2, p < 0.001), MLQ-P score (13.3 vs 21.5, p < 0.001), and MLQ-S score (17.2 vs 21.7, p < 0.001). The proportions of participants who had high presence of meaning or high search for meaning were significantly larger in the non- depressed group.

 

The MLQ score was negatively correlated with the PHQ-9 score (r = -0.56, 95% confidence interval [CI] = -0.68 to -0.41, p < 0.001). The MLQ-P and MLQ-S scores were also negatively correlated with the PHQ-9 score (r = -0.63, 95% CI = -0.74 to -0.50, p < 0.001 and r = -0.34, 95% CI = -0.50 to -0.16, p < 0.001, respectively). Linear regression analysis showed a significant correlation between the MLQ total score and the PHQ-9 score, with a slope coefficient (β) for the MLQ score of -0.35 (95% CI = -0.45 to -0.25, p < 0.001). The model explained 31.3% of the variance (R2) and was statistically significant (F(1,100) = 45.60, p < 0.001). The MLQ-P score explained a larger percentage of the variance (R2 = 0.40, F(1,100) = 66.93, p < 0.001, with β = -0.68, 95% CI = -0.85 to -0.52, p < 0.001), whereas the MLQ-S score explained only 11.5% of the variance (F(1,100) = 13.03, p < 0.001, with β = -0.37, 95% CI = -0.57 to -0.17, p < 0.001). Significance remained after controlling for age and sex: MLQ total score (R2 = 0.44, F(3,98) = 25.39, p < 0.001, with β = -0.33, 95% CI = -0.42 to -0.23, p < 0.001), MLQ-P score (R2 = 0.47, F(3,98) = 29.03, p < 0.001, with β = -0.62, 95% CI = -0.78 to -0.46, p < 0.001), and MLQ-S score (R2 = 0.30, F(3,98) = 13.91, p < 0.001, with β = -0.40, 95% CI = -0.59 to -0.22, p < 0.001).

Poisson regression analysis showed that high presence of meaning was associated with a lower risk of clinical depression (unadjusted risk ratio [RR] = 0.07, 95% CI = 0.01-0.53, p = 0.01), even after controlling for confounding factors (adjusted RR = 0.08, 95% CI = 0.01-0.59, p = 0.01) [Table 2]. The same finding was observed among participants with high search for meaning (unadjusted RR = 0.38, 95% CI = 0.16-0.87, p = 0.02; adjusted RR = 0.36, 95% CI = 0.16-0.84, p = 0.02). The unadjusted and adjusted RRs for clinical depression in participants with both high presence of meaning and high search for meaning were 0.30 (95% CI = 0.13-0.70, p = 0.005) and 0.31 (95% CI = 0.13-0.71, p = 0.006), respectively.

Discussion

During the fourth wave of the COVID-19 pandemic, depression was common among low-income families in Hong Kong, such that 62.7% of participants experienced at least moderate depression. However, participants with a greater sense of MIL had fewer depressive symptoms. Participants with high presence of meaning and high search for meaning were nearly 70% less likely to experience depression, compared with participants who did not have high presence of meaning or high search for meaning. Meaning in life may protect people with lower socioeconomic status from experiencing depression.

Our findings are consistent with the literature that depression has been common during the COVID-19 pandemic.1,32-35 Although significant negative impact of the COVID-19 pandemic on mental health has been reported in low/middle-income countries, few studies examined how the pandemic influences mental health in adults from low-income families in an affluent city. Although Hong Kong has an equitable and efficient healthcare system, our study shows that people with lower socioeconomic status remain highly susceptible to depression. The prevalence of depression is nearly fourfold higher in low-income families than in the general population of Hong Kong.5 We speculate that, during the pandemic, people living in poverty experience more difficulties and stressors, compared with the general population. Because of job loss, higher prices, additional expenses (for face masks, sanitisers, and online learning), and disruptions to healthcare and social services, low-income families are more susceptible to the adverse effects of the pandemic and associated mental health problems. Timely and comprehensive efforts to address the needs of low-income families are important for reducing the risk of depression.

In addition to providing resources to support low- income families during the pandemic, it is important to identify and optimise internal personal factors that can strengthen resilience to life stressors and reduce the risks of mental health problems. We found that a greater sense of MIL was associated with fewer depressive symptoms among people from low-income families, which is consistent with the literature reporting association of MIL with better mental health and lower risk of depression. Individuals can identify MIL when engaging in a creative work or deed, experiencing an event or interacting with a person, or fostering an attitude towards unavoidable suffering.36 Structured meaning-centred psychotherapy strategies have been developed to cultivate a sense of MIL.23

Future studies should investigate whether MIL-promoting strategies can improve mood symptoms in people from low-income families. In the present study, presence of meaning has a greater effect on depression than search for meaning has. Further research is warranted to determine whether promoting a subjective sense of meaning leads to greater improvement in mood symptoms, compared with an approach that primarily focuses on finding MIL.

Our study had several limitations. First, the cross- sectional nature of our study cannot determine the causal associations between MIL and depression. Second, participants were recruited from a single centre using convenience sampling, and the sample size was small. Thus, our sample may not be representative of low-income families in Hong Kong, and caution is needed when generalising our findings to other populations. Third, our study was conducted in the fourth wave of the COVID-19 pandemic in Hong Kong. The circumstances and effects of the pandemic may differ among waves. Fourth, depression was identified using a self-report screening tool, rather than through clinical diagnosis. Nevertheless, we used the established cut-off score for clinical depression and examined the association between MLQ and PHQ-9 scores. Finally, the possibility of bias secondary to other confounding factors could not be ruled out.

Conclusion

During the COVID-19 pandemic, the presence of MIL was associated with fewer depressive symptoms among people from low-income families. Meaning in life may protect against depression. Our findings indicate that timely meaning-based intervention strategies for low-income families are needed to mitigate the adverse effects of the pandemic on mental health.

Contributors

All authors designed the study. EMC acquired the data, analysed the data, and drafted the manuscript. ATCL critically revised the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

As the editor of the journal, ATCL was not involved in the peer review process. Other authors have disclosed no conflicts of interest.

Funding/support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

All data generated or analysed during the present study are available from the corresponding author on reasonable request.

Ethics approval

The study was approved by the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong (Reference: SBRE-20-185) and was conducted in accordance with the tenets of the Declaration of Helsinki.

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